Certified Peer Visitor Training Application Please complete all required fields on this CPV application that are marked with an *. If your CPV application is successfully submitted, you will receive a confirmation email.Contact & Personal InformationTraining Location (City/State or Facility Name or Virtual)* Your Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneWork PhoneEmail* Birthdate*Please enter a valid date in the format (mm/dd/yyyy). MM slash DD slash YYYY Gender*MaleFemaleTransgender M>FTransgender F>MNonbinary/Third GenderNot listedPrefer not to answerSpecify Unlisted Gender Preferred Pronouns Have you ever served in the United States Military?* Yes No Branch of Service*Air ForceArmyCoast GuardNavyMarine CorpsSpace ForceOccupation Race/Ethnicity* American Indian or Alaska Native Asian Black/African American Caucasian/White Pacific Islander Spanish/Hispanic/Latino(x) Race/ethnicity not listed Prefer not to answer Specify Race/Ethnicity* Languages spoken (other than English) Are you a...* Person living with limb loss or limb difference Family caregiver Amputation InformationBecause you indicated that you are a person living with limb loss or limb difference, please supply the following information about yourself. Online forms cannot be submitted without the required fields. If you need assistance, please call 888/267-5669.Date of limb lossPlease enter a valid date in the format (mm/dd/yyyy). MM slash DD slash YYYY Type of Limb Loss/Limb Difference*Select all that apply. Above Elbow – Left Above Elbow - Right Above Knee – Left Above Knee - Right Below Elbow – Left Below Elbow - Right Below Knee – Left Below Knee – Right Elbow Disarticulation - Left Elbow Disarticulation - Right Finger(s) - Left Finger(s) - Right Foot - Left Foot - Right Forequarter Hemicorporectomy Hemipelvectomy Hip Disarticulation Hip – Left Hip - Right Partial Hand – Left Partial Hand - Right Partial Foot - Left Partial Foot – Right Rotationplasty Shoulder Disarticulation Shoulder - Left Shoulder – Right Symes Toe(s) - Left Toe(s) - Right Wrist Disarticulation - Left Wrist Disarticulation - Right Not listed Specify Type of LImb Loss/Limb DifferenceBecause you selected Not listed above, please indicate here. Amputation Level*Select all that apply. Unilateral Bilateral Trimembral Quadrimembral Cause(s) of Limb Loss/Limb Difference*Select all that apply. Cancer Congenital Disease Related Infection Sepsis Trauma Type 1 Diabetes Type 2 Diabetes Unknown Not Listed Specify Cancer Indication Specify Congenital Indication Specify Disease Related Indication Specify Infection Indication What was the cause of the trauma?AutomobileBicycleBoatingBurnElectrocutionFallFarmingGunshotJet skiingLandmineLawnmowerLoggingMotorcycleOtherPedestrianPlane CrashShark AttackSportsSuicide AttemptTrainWarWater SkiingWork-RelatedOther CauseBecause you selected Not listed above, please indicate here. Assistive Devices*Select all that apply. Cane Crutches Prosthesis Scooter Stubbies Walker Wheelchair Other Other Assistive DevicesBecause you selected Other above, please indicate here. Other Considerations & Additional Information Vision Impairment Hearing Impairment Use of support animal Other Other additional information (specify)Because you selected Other above, please indicate here. Peer Visitor Program QuestionsHow did you learn about the peer visitor program?*Are you a member of a support group?* Yes No Support Group Name Support Group Leader What skills, attributes and other experiences do you have that would be helpful in volunteering as a peer visitor?*Please list the name of the hospitals / rehab facilities from which you will receive referrals. Please write a brief statement about what you expect to gain from participating in the CPV program.*If you successfully complete the CPV course, may the Coalition share your name, level & cause of limb loss / limb difference, and contact information with:* Your local hospitals Your local support groups Background Check: The healthcare community often requires volunteers to pass a background check prior to having contact with vulnerable people, and our board and committees agree that this layer of professionalism and security should be offered to the people we serve. Therefore, we will run a criminal background check on all certified peer visitor candidates.Have you ever been convicted of a crime other than a minor traffic offense?* Yes No If yes, please explain:* Does the Amputee Coalition have permission to perform a background check on you?* Yes No I authorize investigation of all statements herein, including any checks of criminal records, and release the Coalition and all others from liability in connection with same. I also understand that misrepresentations or falsifications herein or in other documents completed or submitted by the applicant will result in dismissal, regardless of the date of discovery by the Coalition. If permission is given, you will receive an email from the Coalition with a link to Sterling Volunteers background check system within 2 weeks of application submission.Professional Letters of RecommendationPlease provide three professional letters of recommendation (such as your prosthetist, other healthcare provider, minister, support group leader if appropriate). Family members cannot be listed as a reference.File Upload*Upload your files or send them by email to peersupport@amputee-coalition.org Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 3 MB, Max. files: 3. CAPTCHAPlease review your application to make sure all required fields are filled in before submitting. If required fields are missing, there will be an error message and your submission will not go through. If your CPV application is successfully submitted, you will receive a confirmation email. If you need assistance, please connect with the Amputee Coalition’s Peer Support Department by calling 888/267-5669 or emailing peersupport@amputee-coalition.org. NameThis field is for validation purposes and should be left unchanged.